Chapter 48 Flashcards
A client is being observed after a routine sigmoidoscopy with a tissue biopsy. Which assessment finding will the nurse report to the health care provider?
rectal bleeding
Bleeding is a possible complication following a sigmoidoscopy. It must be reported immediately to the health care provider.
A client is preparing to undergo a stool DNA (sDNA) test to screen for colon cancer. What preprocedure teaching does the nurse provide?
“No special preparation is needed prior to completing this test.”
The nurse will teach the client that no special preparation is needed prior to completing the Cologuard test. Cologuard is a home screening test that the client can perform at any time, with no traditional bowel cleaning preparation or fasting necessary.
A client is admitted to the hospital with severe right upper quadrant (RUQ) abdominal pain. Which assessment technique does the nurse use for this client?
Examines the RUQ of the abdomen last following all other assessment techniques.
If the client reports pain in the RUQ, the nurse examines this area last. This sequence prevents the client from tensing abdominal muscles because of the pain, which would make the assessment difficult.
The sequence for examining the abdomen is inspection, auscultation, percussion, and then palpation. This sequence prevents the increase in intestinal activity and bowel sounds caused by palpation and percussion. The client would be positioned supine with the knees bent while keeping the arms at the sides to prevent tensing of the abdominal muscles. If a bulging, pulsating mass is present during assessment of the abdomen, the nurse must never touch the area because the client may have an abdominal aortic aneurysm, a life-threatening problem. The nurse would notify the health care provider of this finding immediately!
The nurse is assessing a very thin client who has come to the emergency department with acute abdominal pain. Upon assessment, visible peristaltic movements are noted. What is the appropriate nursing action?
Monitor laboratory values for possible pancreatitis.
The nurse will report the finding to the health care provider, as it is possible that the client has an obstruction. Peristaltic movements are rarely seen except in thin clients.
While working in the outpatient procedure unit, the RN is assigned to four clients. Which client will the nurse assess first?
A 51 year old who just had an endoscopic retrograde cholangiopancreatography (ERCP).
ERCP requires conscious sedation, so the client needs immediate assessment of respiratory and cardiovascular status. The endoscopic procedure and nursing care for a client having an ERCP are similar to those for the EGD procedure, except that the endoscope is advanced farther into the duodenum and into the biliary tract.
A 54-year-old client being discharged after a colonoscopy, a 58-year-old client who is going to have a sigmoidoscopy, and a 60-year-old client with questions about an endoscopic ultrasound examination are not at risk for depressed respiratory status. They can all be seen following the client who just had an ERCP.
Which factor does the nurse identify that places a client at risk for gastrointestinal (GI) problems? (Select all that apply.)
Smoking a half-pack of cigarettes per day
Taking nonsteroidal anti-inflammatory drugs (NSAIDs)
Financial concerns
Use of herbal preparations
A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform? (Select all that apply.)
Visually observe for contour and symmetry.
Ask for a pain scale rating on a scale of 0-10.
A hospitalized client with ongoing abdominal tenderness reports an increase in generalized abdominal pain today. Which assessment technique will the nurse perform? (Select all that apply.)
Visually observe for contour and symmetry.
Ask for a pain scale rating on a scale of 0-10.
The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency?
Intrinsic factor
ntrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia.
The nurse and health care provider are discussing a client who has pernicious anemia. The nurse anticipates that the client has which deficiency?
Intrinsic factor
ntrinsic cells are produced by the parietal cells in the stomach. This substance facilitates the absorption of vitamin B12. Absence of intrinsic factor causes pernicious anemia.
The nurse is teaching an older adult client. Which gastrointestinal problem does the nurse discuss that takes place during the normal aging process?
Decreased hydrochloric acid levels
n older adults, decreased hydrochloric acid levels (hypochlorhydria) results from atrophy of the gastric mucosa.
A decrease in lipase production results from calcification of pancreatic vessels. A decrease in the number and size of hepatic cells leads to decreased liver weight and mass. Peristalsis decreases, and nerve impulses are dulled.
The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has resumed?
Ask if the client has passed flatus (gas) within the previous 12 to 24 hours.
The nurse is assessing an alert client who had abdominal surgery yesterday. Which assessment method will the nurse use to most accurately determine whether peristalsis has resumed?
Ask if the client has passed flatus (gas) within the previous 12 to 24 hours.
Which client does the charge nurse on the adult medical unit assign to an RN who has floated from the outpatient gastrointestinal (GI) clinic?
Client who has had laxatives administered and needs monitoring before a colonoscopy.
The client who needs laxatives administered and effectiveness monitored before a colonoscopy is the least complicated client. This client would be assigned to the float nurse who would have the experience and education to adequately care for this client.
Discharge instructions following an ERCP, assessment of an admitted acutely ill client, and monitoring a client who is receiving conscious sedation is accomplished best by a nurse with experience in caring for adults with acute GI problems.
Which client does the charge nurse assign to an experienced LPN/LVN working on the adult medical unit?
A 32 year old with constipation who has received a laxative.
